“A scarlet letter”: Stigma and other factors affecting trust in the health care system for women seeking substance abuse treatment in a community setting

Abstract

Background: Trust in health care has been shown to influence health care utilization, perceptions of fair treatment, and health outcomes in the general population. The literature on trust in health care in individuals with a history of substance use disorder (SUD) is more limited, primarily examining the patient-provider relationship. Women seeking substance abuse treatment in community-based programs have higher rates of prior trauma and health disparities compared with male counterparts and the general population. With higher rates of prior trauma, this population is theoretically at high risk of decreased interpersonal trust and altered interpersonal relationships. Objective: This study sought to identify factors influencing trust in the health care system for women seeking substance abuse treatment in a community-based residential treatment program. Methods: Six client focus groups (n = 30), 1 provider focus group (n = 7), and 2 individual clinical administrator interviews (n = 2) were conducted between November 2016 and August 2017. Focus groups and interviews were audio recorded and transcribed. Coding and coding reconciliation were conducted by 2 independent coders. Themes were extracted and analyzed from sorted and coded quotes. Results: Six themes emerged. Factors that influence trust in the health care system in this population include (1) prior experiences with diagnosis, treatment, and outcomes; (2) stigma of addiction; (3) payment and reimbursement structure; (4) patient rights and protections; (5) efficiency-driven care; and (6) the health care system's role in causing and/or enabling addiction. Conclusions: These themes demonstrate a general distrust of the health care system by women in this population. Distrust is influenced by a perception of a health care system providing care that is variable in quality, often stigmatizing, unaffordable, efficiency driven, and often influencing individuals’ SUD. This aligns with and extends prior literature around trust of health care in individuals with SUD. Future directions in research include formally assessing the impact of trust on health outcomes such as treatment entry and retention.

Keywords:

• Health care trust
• women substance use disorder
• stigma of addiction
• trauma informed care

Acknowledgments

We would like to thank Dr. Velma Murry and Dr. Consuelo Wilkins for their revisions and suggestions for the final manuscript.

Author contributions

J.C. was principal investigator on this study, helped develop the study protocol, enrolled subjects, conducted interviews, coded transcripts, reconciled coded transcripts, conducted theme extraction and analysis, and contributed to and revised the final manuscript. S.A. helped develop the study protocol, conducted theme reconciliation, and contributed to and revised the final manuscript. K.B. helped develop the study protocol, coded transcripts, reconciled coded transcripts, and contributed to and revised the final manuscript. D.M. recruited subjects and contributed to and revised the final manuscript. J.M. enrolled subjects, conducted interviews, and contributed to and revised the final manuscript. D.S. helped develop the study protocol and contributed to and revised the final manuscript.

Additional information

Funding

This work was supported by internal funding from the Vanderbilt University Office of Medical Student Research and the Vanderbilt Medical Scholars Program. It was further supported by CTSA funding (TL1TR002244; 5UL1TR002243-02; 3U54MD007593-10S1) from the National Center for Advancing Translational Sciences (NCATS). Its contents are solely the responsibilities of the authors and do not necessarily represent the official views of NCATS or the National Institutes of Health. The funding organization had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.